Hoffman, Gayle NEW YORK STATE DEPARTMENT OF HEALTH �4(1
Vital Records Section 1 Burial - Transit Permit
Name First Middle Last I Sex
Date of Death rAge If Veteran of U.S. Armed Forces, 1
O1 - \'L- 7-01i ! (99 War or Dates N 0 _
ace of Death ' Hospital, Institution or 31 Sa Ste• >?1,Q} , y.D
Town or Village G\en,S Street Address G\-e n.S CO 5 , Nil
;� Manner of Death Natural Cause El Accident Q Homicide [0 Suicide Undetermined Pending
Circumstances Investigation
.148 Medical Certifier Name Title
Address
?ate �; ; o � CD(---Lens
�
y. \ (C r\ �am� .,l Pc&- \ ; Cp C s ¶o,\\5.) ..N)-_ logo)
>:I Death Certificate Filed District Num 1 Regist er
City, Town or Village Ll Pc l 1) er naI
Date ! Cemetery or Crematory
❑Burial 1 0—I t`i LicA 4 ? ne v,)e C d.-Vo`y
Address
• X Cremation 1'7 Q
Z Date Place Removed
Z Q Removal ";, and/or }Hid
and/or _ �—._ _
ii-i Address
Hold i
d� Date 'Prot of
NTransportation •- Shipment
a by Common I} Destination
Carrier
C Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
;; Permit Issued to ;� i Registration Number
a Name of Funeral Home A1Ct i_ ��a�IC/ /) Zaitrr rcc.ner(L) /}amp,
1 Address fi
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
* Permission i h`rereby granted to dispose of the human remains descri ed a ov s i ed.
+'j] Date Issued / " Registrar of Vital Statistics -• X
a: (signature)
>'<s District Number io/ Place 67./? is c// /
I certify that the remains of the decedent identified above were disposed of in accordance
e with this permit on:
E, Date of Disposition i-n-lti Place of Disposition tli j 4r _- _
2 (address)
W
CA
CC (section) numb (grave number)
AName of Sexton or Person in Charge of Premises _ trrJi nr�it.2 (please print)
1 . Signature SignatureL ` Title CI' ill
!
(over)
DOH 1555 (9/98;